flowchart TD
A{Crossley et al} --> B(3 months)
A--> C(6 months)
A--> D(12 months)
My name is Mick.
My name is Mick.
My name is Mick.
Kambhampati & Vaishya, 2019
How does muscle strength and funcional performance change over time after ACLR
A group of systematic Reviews with meta analysis
Databases: MEDLINE, EMBASE, CINAHL, Scopus, Cochrane CENTRAL, SPORTDiscus
Inclusion criteria: primary ACL injury, aged 18-40 years, with a quantitative measure of muscle strength or hop performance
Methodological Quality Assessed on domains outlined by Cochrane Collaboration
Comparison:
A group of systematic Reviews with meta analysis
Additional Criteria:
Example: ACL Side compared to the contralateral side
ROM = 0.9 95%CI[0.85-0.95]
= ACL side is 0.9x weaker than the contralateral side
= 10% deficit in ACL side strength
Allow multiple (correlated) pieces of information from the same study to be included in a meta-analysis
flowchart TD
A{Crossley et al} --> B(3 months)
A--> C(6 months)
A--> D(12 months)
metafor package.Random effects:
(timepoint | cohort)
Fixed effect: timepoint
Robust variance estimation methods using clubSandwich package 🥪
Is comparing to the contralateral limb equivalent to comparing
to uninjured controls
Between-person deficits were 1.53x greater than within person (95%CI 1.15 to 2.19)
Take aways
Limitations
Hop tests are widely used by clinicians after ACLR (>90%)
Take aways
Limitations
A similar story to the muscle strength data:
28 studies 🇦🇺 🇬🇧 🇺🇸 🇮🇷 🇯🇵 🇩🇪 🇹🇷 🇧🇷 🇳🇴 🇰🇷
1103 ACL injured (all except 12 reconstructed) + 1145 controls
Mean age ranging from 19 to 38 years
Most timepoints between 7-12 months post ACL surgery
Limited information on activity levels
No consistent or widespread weakness of the hip or calf muscles after ACL injury
Despite all studies included showing significant quadriceps and hamstring weakness when measured
Limitations
Low sample size especially for hip IR, flexion, soleus and dorsiflexors
Variability and heterogeneity
Very low certainty evidence
123 men and women
Aged 18-50 years
Recruited at 1 year post-ACLR
ACLR with hamstring graft from 2 Melbourne surgeons
No structured rehabilitation
Measured at 1, 3, 5 and 11 years (Culvenor, 2016, 2017; Patterson 2018, 2019, 2020)
PROMS
Physical Tests
Imaging
`
| n = 123 | |
|---|---|
| Women (%) | 43 (35%) |
| Age (years) | 29.9 (8.8) |
| BMI (kg/m2) | 26.1 (3.9) |
| 1 year KOOS4 | 81.1 (11.5) |
Mean (SD) unless specified
| n = 123 | |
|---|---|
| Women (%) | 43 (35%) |
| Age (years) | 29.9 (8.8) |
| BMI (kg/m2) | 26.1 (3.9) |
| 1 year KOOS4 | 81.1 (11.5) |
Mean (SD) unless specified
| n = 123 | |
|---|---|
| Women (%) | 43 (35%) |
| Age (years) | 29.9 (8.8) |
| BMI (kg/m2) | 26.1 (3.9) |
| 1 year KOOS4 | 81.1 (11.5) |
Mean (SD) unless specified
| Total n = 117 | Index knee |
Contra knee |
|---|---|---|
| ACL rupture | 6 | 5 |
| Arthroscopy | 7 | 2 |
| Meniscal surgery | 3 | 1 |
| Meniscal injury | 2 | 0 |
| Collateral ligament | 2 | 2 |
| Cartilage injury | 1 | 0 |
| Knee effusion | 0 | 2 |
| Total | 21 | 12 |
- Generalised linear mixed models with an ordered-beta distribution - Random effects for participants
Fits in with the previous systematic reviews
Still unclear whether prognosis can be modified by intervening on functional performance and muscle strength in the medium-term post-ACLR
Watch this space!
Michael Girdwood, Adam Culvenor, Brooke Patterson, Ali Guermazi, Tim Whitehead, Hayden Morris, Ebonie Rio, Kay Crossley
Physical Therapy in Sport, 2023
Hip External Rotation & Internal Rotation with HHD
Measured only at 1 year with hand held dynamometer according to Kemp et al 2013, JSAMS protocol
🔻0.1Nm Strength = Odds Ratio: 1.64 (95%CI 1.09 to 2.50)
Hip ER may influence symptomatic and structural outcomes as it is critical to single leg functional tasks.
Relationships are modest, and likely multi-factorial - need further confirmation
ER specific weakness could result from:
lack of training/rehab
weakness broadly of the entire lower limb (not specific to the hip).
Hip ER strength was impaired on the injured side at 1 year post ACLR
This may contribute to symptomatic, and structural outcomes up to 5 years post-operatively.
Contrary to initial hypothesis, hip rotation strength was not associated with PFJ structure
m.girdwood@latrobe.edu.au
n = 120
Men and women post-ACLR
Aged 18-50 & >2 years post surgery
Runners
Symptomatic Cohort
Peak isometric
quadriceps (knee extension) and hamstring (knee flexion) torque
Knee Osteoarthritis Outcome Score - KOOS
Beta-regression models modelled the relationship between muscle strength and self-reported function (KOOS subscales).
| Measure | Runners (n = 33) | Symptomatic (n = 87) |
|---|---|---|
| Age (years) | 32 (7) | 31 (6) |
| % Female | 36% | 36% |
| BMI (kg/m2) | 23.8 (2.8) | 27.9 (5.7) |
| Time since surgery (yrs) | 9.2 (7.4) | 2.7 (0.3) |
| KOOS4 | 83.0 (15.9) | 65.6 (12.8) |
| Quadriceps Strength (Nm) | 207.5 (54.8) | 184.2 (59.7) |
| Hamstring Strength (Nm) | 97.4 (26.3) | 83.1 (29.0) |
The runners had stronger quadriceps and hamstrings, and reported less symptoms.
Time since surgery was not related to muscle strength.
No meaningful relationships between thigh muscle strength and self-reported function
Findings were consistent for both runners and symptomatic cohorts (no interaction effect).
Thigh muscle strength was not associated with self-reported function in people >2 years post-surgery
Findings were consistent in a group of runners and a lower functioning symptomatic cohort.
Other non-physical factors may be more important to longer term knee health